Find the solutions, not blaming the victim...

Tuesday, April 15, 2008

"Don't Blame Crowded ERs on the Uninsured" is the pitch-perfect headline of an article by Suzanne Bohan in the San Mateo County Times and other papers.

The articles reports on a UC-San Francisco study that reports that asks "Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States?" and answers "no." In fact, the "proportion of adult ED visits by persons without insurance was stable across the decade," roughly in the 14-15% range.

Despite the belief that the uninsured are the majority of those crowded in our emergency rooms, I note that this figure is a bit lower than the overall percentage of uninsured people in the country, which is around 16%.

This is consistent with other findings, such as a 2004 Urban Institute report by researchers Zuckerman and Shen on ocassional and frequent ER users. That paper concludes, in part, "The uninsured and the privately insured adults have the same risk of being frequent users... It seems hard to blame the overcrowding of EDs on the uninsured."

MISSING THE MESSAGE: Some conservative commentators will use this research to attack the notion that of a "hidden tax" that we all pay in our premiums for having such a large uninsured population, and to attack the notion of health reforms and coverage expansion generally. I get a very different lesson from the study.

I too have been a skeptic of the Governor Schwarzenegger's "hidden tax" rhetoric, because it led people to blame the uninsured for high health costs, rather than the reverse.

If the uninsured go to the emergency room, they have only a right to be stabilized. But even then, they get a bill--typically the biggest bill they will see in their lives, and often one that is inflated well above what an insurer would pay for the same service. No wonder they may actually go to the ER less.

LOTS OF FACTORS: That said, there's nothing inconsistent with saying that the uninsured, when they finally do go to get care, are in a worse condition since they let their conditions linger and mestatisize, costing the health system more money in the long run. Or that the uninsured get the bill, but some face bankruptcy not being able to pay, and as a result leave the hospital unpaid.

In other words, I think the real world in health care is more complicated than one cause. Some uninsured get the care they need. Others go without and simply die. And in between, some uninsured wait until the problem gets worse. And some of these factors end up costing the health system. So reforming health and increasing coverage is needed and urgent, even for the regular, insured California.

SOLUTIONS: So how much is the "hidden tax?" I don't know, but it's real. But I think the focus should be on fixing the system, not the victims of that system:

* We all pay when McDonald's, Wal-Mart, or Applebee's don't, when some employers don't pay their fair share. Those who are uninsured are those who fall through our health system that relies on voluntary employer contributions.

* We should ensure that those who are uninsured are not overcharged and thus discouraged from getting needed care. California passed a fair hospital pricing law in 2006, and other protections would be helpful.

* We who are *insured* would not go to the emergency room as much if we had the ability to get timely access to care to primary care and specialists. There's pending regulations for insurers and providers at the California Department of Managed Health Care.

Our health care system doesn't have just one problem, and doesn't have just one solution. The new research helps us understand that.

Labels: ExpandingCoverage, Hospitals, Research, TimelyAccess, Uninsured

posted by Anthony Wright | Permalink | 10:45 PM


 

The DMHC Oversight Hearing...

Thursday, March 27, 2008

HEALTH ACCESS UPDATE
Friday, March 28th, 2008


SENATE PANEL QUESTIONS HMO REGULATOR
* Lawmakers question Department of Managed Healthcare’s oversight of health insurers
* Inquiry into regulations for timely access, discount plans, rescissions, language access and mental health parity
* Sen. Kuehl sees "pattern" of siding with industry against consumers
* Laws passed more than five years ago still not implemented


Click Here for What's New on the Health Access WeBlog: Health Care Consumers Views; GAO Individual Market Investigation; More Debriefings on California Health Reform; A Health Reform Backlash Against San Francisco Restaurants?; Health Budget Cuts Nationally; Shooting for 60 Votes; 1,000 Posts!; Web Wonkery; McCain's Misstep: Do We Go to the Doctor Frequently?; The Hot Hearing for the Week; Mayor Newsom Suing Sacramento Over Medi-Cal Rates; So-Called Consumer Directed Health Plans; Overseeing the DMHC


SACRAMENTO--At a special hearing of the Senate Health Committee on Thursday, Department of Managed Health Care Director Cindy Ehnes was questioned for over nearly seven hours about her department’s handling of five separate regulations and whether it had met its charge as a consumer protection agency in implementing and enforcing laws to help patients. “This hearing is meant to provide a level of oversight to ensure that legislation that is passed gets implemented in a way that is consistent with the way it was intended,’’ said Sen. Sheila Kuehl, chair of the Senate Health Committee.

At issue were three laws, passed in the late 1990s and earlier this decade, which still have not been put into practice: Timely access to health care, access to health care that is both culturally and linguistically sensitive and mental health parity. Additionally, Ehnes was interrogated about the Department’s rationale for regulations regarding retroactive cancellations of health policies and so-called "discount health cards".

For more detailed information on all these issues, you can visit the Health Access website and blog. As well, the Senator posted a detailed agenda and background papers on her website, at:
www.sen.ca.gov/kuehl


TIMELY ACCESS TO CARE

Background: First on the list was the issue of timely access to care, which were intended to prescribe specific time-elapsed standards for how long it should take patients to get into to see a physicians. The law was passed in 2002, and after many years of hiccups, regulations were on the path to implementation in 2007. The regulations spelled out exactly how quickly patients should be able to get in to see a doctor in certain situations. (I.E. Urgent primary care needs: 24 hours; Routine primary care needs: 10 days; Urgent specialty care: 72 hours; Routine specialty care: 14 days)

But in December, the Department yanked that version, stripped out all specific requirements, and left it up to health plans to determine their own standards, as had been the practice in the years before the law was passed. Health Access California and Western Center for Law and Poverty testified that the law did not meet the legislature's intent in having the Department set clear, prescriptive standards. Last month, the Office of Administrative Law rejected the regulations, saying the department had not allowed enough time for public comment given the dramatic changes in the regulations. To read Health Access' writings on this, click here.
The difference between the August and December versions of the regulations was so stark that Sen. Sam Aanestad, R-Grass Valley, asked, “It looks like the department just punted. What was the amazing turnabout?’’

Department’s take: Ehnes said she felt that the August regulations – 26 pages – were too complicated and would force plans to micromanage physicians they contract with. She said the department focused on the clinical triage via phone, where patients could call in and get a professional to tell them what they needed to do. Health Access’ Beth Capell later said this telephonic triage was available during limited times -- weekdays during work hours.

Legislative comment: “Regulations are supposed to go further than the statute. Sometimes they are going to be very complicated. I would encourage a little more complication,’’ Kuehl said. She urged that the Department set prescriptive, time-elapsed standards when developing new regulations in the new year. Aanestad indicated he thought the Department was "almost there" with previous version of the regulations that had set standards.

DISCOUNT HEALTH CARDS

Background: Discount health cards aren’t health plans, but cards that consumers pay a monthly premium, for access to a list of physicians that will purportedly provide them discounts. The problem is, often, physicians don’t know they’ve been put on a list, and consumers don’t know what the base price off which they receive a discount, making the discounts meaningless. These plans are often marketed toward lower-income or limited-English consumers who believe they are actually buying health coverage, and these plans rely on this confusion to thrive.

The plans have been deemed illegal by the state Attorney General; but there has been confusion about if they should be allowed or licensed and regulated, and even what agency should do the regulating. The DMHC has started a process of developing regulations to license these discount cards, working with the industry. Health Access testified that while the value of these products was questionable, any regulations must at a minimum ensure real discounts to a real network of providers with real notice of what consumers are and are not getting for their money.

Department’s take: The department has investigated 53 discount health plans and ordered cease and desist orders against 7. Ehnes said developing regulations and licensing such products was not meant to be an endorsement, but to try to better understand the products.

Legislative comment: Kuehl asked the department, as it continued its work, to strongly consider whether these products offer any real economic value to consumers.


RESCISSIONS

Background: In the past couple of years, the startling practice of retroactive cancellation of policies by insurers has arrested the public’s attention. Consumers, who have been paying monthly premiums and believed they are insured, receive high-dollar treatments for cancer, heart disease and the like. These expensive treatments often trigger insurance companies to review the enrollees’ initial application and rescind policies, claiming enrollees did not properly disclose pre-existing health conditions. Policies are cancelled, retroactively, as if consumers were never insured. Consumers are then sometimes left with thousands –if not hundreds of thousands of dollars -- in debt for treatments they believed were covered. The courts have determined this practice is illegal unless consumers willfully misrepresent their health status.

Department’s take: Ehnes said the DMHC has been aggressive in investigating plan behavior since the practice came to light. The department, along with the Department of Insurance are developing regulations so that plans do not have the ability to rescind without reason and that consumers can’t misinterpret applications.

Legislative comment: Kuehl’s primary concern was how consumers could obtain coverage after they’ve been cancelled. These cancellations occur on the individual market where consumers are often denied coverage due to pre-existing conditions. Once consumers’ coverage is cancelled, it would be impossible for them to obtain coverage through any carrier.Aanestad believed the department was not properly protecting consumers and making that the focus. “The first priority is to reinstate coverage for consumers. The second priority is to make headlines and change the industry, but it doesn’t sound like that’s really happening.’’


CULTURAL AND LINGUISTIC ACCESS

Background: In 2003, the legislature passed a law, SB853(Escutia), that required health plans to ensure that the consumers who did not speak English as a first language had proper medical interpretation services. Up until then, consumers brought in their children to translate, did not get care, or got the wrong care because they were unable to communicate with their doctors. This is particularly important in California where 55 percent of the population reports not speaking English well. The California Pan-Ethnic Health Network, Latino Issues Forum, and other groups were concerned that the notice about these new rights were left to the industry to determine, without consumer input. Plans have complained it is costing them millions to translate materials.

Department’s take: Ehnes said she was committed to this issue and was attempting to evaluate all aspects, including whether the regulations go beyond the law and whether it will cost too much.

Legislative comment: Kuehl said when the legislature passes something, that’s the rule. “We don’t care what it costs everybody. Cost is important…but that’s not the top consideration. …We really mean it about providing real access to language minorities,’’ said Kuehl, who was also critical about the department’s process in listening to all stakeholders and allowing enough time to comment on regulations. “Please push the envelope on this one, because I know you want to.’’


MENTAL HEALTH PARITY

In 1999, the Legislature passed mental health parity, providing consumers with access to mental health benefits equal to coverage in other health services. But to this day, consumers are still finding it difficult to obtain mental health services they need on the same level as other health services. Timely access to providers remains a problem as well as plans’ treatment and financial obligation toward mental health. The Senators urged the department to be more aggressive about following up on surveys and studies that found consumers lacking access to mental health.

PARTING NOTES

Ehnes said the department would continue to work on these – along with other issues – under the department’s jurisdiction. Kuehl reiterated that the hearing was intended to ensure that laws were actually implemented and not allowed to wither once passed. She also continued to encourage the department to have more open and collaborative process.

For more information, contact Elizabeth Abbott, director of administrative advocacy at Health Access California, at eabbott@health-access.org. Interested organizations can also contact the author of this report, Hanh Kim Quach, policy coordinator at Health Access, at hquach@health-access.org.

Labels: DMHC, Kuehl, LanguageAccess, Sacramento, TimelyAccess, Updates

posted by Anthony Wright | Permalink | 10:12 PM


 

Back in session... and the hot hearing for the week...

Tuesday, March 25, 2008

The legislators came back to Sacramento this week after spring break... and it's getting frantic, quick. Bills (see the Health Access bill list) introduced this year only have a few weeks to pass their first policy committee.

While the budget and policy committees continue their regular work, the most interesting and high-profile hearing this week will probably be the Senate Health Committee, chaired by Senator Sheila Kuehl, hold a special Thursday session.

The hearing is entitled "Consumer Protection under the California Department of Managed Health Care: Adequacy of Implementation and Enforcement," is expected to take several hours and maybe more.

The issues to be discussed at this informational hearing are meaty, as it asks for reports on the DMHC's implementation of regulatons in many areas of strong interest to consumer advocates, including timely access, so-called "discount health plans," rescissions, language access, and mental health parity.

We're posted some about the pending regulations to ensure patients have timely access to care. A month ago, Senator Kuehl urged the Department to withdraw their proposed regulations, stating that they were not in line with the legislature's intent when passed AB2179. The author, Assemblywoman Rebecca Cohn, has been termed out, but Health Access California was a sponsor, and Senator Kuehl was a member of the Legislature that voted for it.

But it's clear that this hearing is about more than just timely access--or even about the other key issues. It's about being clear that the DMHC should be focused on consumer protection as its core mission--it's the reason that the DMHC was created in the first place. There's too many important issues for anything else to get in the way.

Labels: DMHC, Kuehl, Sacramento, TimelyAccess

posted by Anthony Wright | Permalink | 3:55 PM


 

Overtime for timely access standards...

Monday, March 10, 2008

Aurelio Rojas of the Sacramento Bee had a good Sunday story on the long saga of the timely access to care regulations at the Department of Managed Health Care.

As has been reported on this blog before, after going back-and-forth with specific standards, the DMHC decided a few months ago to simply let the HMOs determine their own standards. As the article indicates, Health Access California and Western Center for Law and Poverty were prepared to go to court, since it's just unacceptable for the DMHC to abdicate their role to insurers, and the regulations simply did not implement the intent of the legislature.

But that was avoided, since the Office of Administrative Law rejected the regulations on a technical process issue. The Bee has a statement by the DMHC:

"With the disapproval of the timely access regulations, we will take the
opportunity to re-examine the concerns of all stakeholders and determine the
best approach going forward."

It would be inappropriate for the DMHC to respond to just the procedural issues and resubmit the same, flawed regulations. We truly hope the Department, in the short winodw of time before they need to resubmit in the next few months, commits to a process that results in clear standards of timely access, standards that consumers can understand and demand the next time they are told they can't see a specialist for two months.

Until such a process is set, the next step is a special oversight hearing by the Senate Health Committee, chaired by Sen. Sheila Kuehl, set for later this month.

Labels: DMHC, InTheNews, TimelyAccess

posted by Anthony Wright | Permalink | 6:41 PM


 

A coda on confirmation...

Wednesday, February 27, 2008

By the way, Secretary Dale Bonner was confirmed today by the Senate Rules Committee.

But not before several Senators asked a series of tough questions about his oversight over the Department of Managed Health Care. This was part of a wide-ranging hearing that reflected the broad scope of the department, from housing to transportation issues as well.

Senator Padilla asked about the level of fines levied at Blue Cross and other insurers over rescissions, and said he's "not convinced [they] get to the level of deterrence needed" and that he's thinks that "all of the players have not gotten the message." After being asked about how the Department is made aware of consumer complaints, Bonner stated "I don't think [the Department] is sufficiently pro-active."

Senator Padilla also asked about the letter by Senate Health Committee Chair Kuehl expressing concern that the timely access regulations adopted are not reflecting the will of the legislature. He ask about the Department's adoption of new regulation that allow the health plans to set their own standards: "that sounds a little permissive to me." He made the argument for such clear, enforceable standards. "We know that justice delayed is justice denied. Well, health care delayed is health care denied," and he pointed out the additional costs and burdens that such delays place on emergency rooms. Padilla also asked about the implementation of language access regulations. Bonner stated that he thought the implementation of language access is "all over the map," and that "I don't believe we have enough coherency" with regard to the goal of language access.

Senator Ashburn asked about the appropriateness of Blue Cross' letter to get doctors to reveal information to the insurer that would get patients retroactively denied. Bonner stated that he didn't read the infamous letter himself, but that he recognized "the discomfort in anything that interferes in the doctor-patient relationship," and he thought Blue Cross' restraction of the letter "confirms that there was a serious problem." asked more specifically about the actions that Bonner took with regard to the issue, including any conversations with DMHC Director Cindy Ehnes. He said he hadn't spoken with her directly, but did through staff, and was satisfied that there was a investigation underway. Later, Senator Perata followed up Ashburn's scolding, saying "you should have seen the letter, and you should have been all over it."

Senator Perata also agreed about the need for more responsive DMHC. "This isn't an academic exercise, for those who are in trouble with their HMO, someone who is being horsed around." Senator Perata also urged higher fines: "you have to put a sharper point on it," he said, and later, "fines are a real attention getter." Senator Perata even asked if the DMHC should be in his far-flung Business, Transportation, and Housing Agency. Bonner indicated that it should, given the kind of expertise it regarding business oversight and solvency issues.

Consumers groups like Health Access California and Western Center on Law and Poverty were there, not to oppose Bonner's confirmation, but to make clear our concerns about how the Department is abdicating their responsibilities to the industry they are supposed to be overseeing.

Senator Cedillo followed up on the language access issue and making sure people have notice of their rights under the law, saying "this is an absurdity. You don't know you have a right unless someone communiciates it to you. If you don't know it, it doesn't exist.... It's the law. The Escutia law is the law." Senator Perata suggested that Bonner didn't want former Senator Escutia coming back to ask questions.

Secretary Bonner was confirmed, but promised to reach out to stakeholders, including consumer groups, to deal with these issues and the other issues presented.

Labels: DMHC, Perata, TimelyAccess

posted by Anthony Wright | Permalink | 8:44 PM


 

What they don't teach in civics class...

While we glow about how the Department of Managed Health Care's regulations on timely access to care were returned to them yesterday -- without approval -- by the Office of Administrative Law, we also want to take the opportunity to talk about the obscure process in state government called rulemaking.

I'll strongly note here that the OAL's refusal to finalize DMHC's proposed Timely Access regulations had nothing to do with how miserable the regulations actually were. Office of Administration Law merely dinged DMHC because they did not follow the proper waiting periods and rules -- (hey, we'll take our wins where we can get them). This is an importnat point as we embark on another year of rulemaking for Timely Access to Health Care standards.

First, I want to point everyone to the Office of Administrative Law's handy dandy lay person's guide on How to Participate in the rulemaking process.

Secondly, some context. Here's how the Timely Access regulations came to be:

• January 1, 2003: AB2179 (Cohn) takes effect, having passed in 2002, requiring the state to adopt regulations to ensure that enrollees have "timely access to needed health care services.'' (Timely access means reasonable waiting times for appointments with physicians, quick and timely care when a patient is sick or needs services, etc. )
  
• January 1, 2004: The date by which DMHC was supposed to have adopted regulations.


• July 9, 2004: DMHC begins writing regulations, but withdraws them in April 2005 because of feared "unintended consequences" and restarts discussions with various parties, including insurers, providers and consumers on how to craft the rules.


• January 11, 2007: DMHC reopens the rulemaking process with Office of Administrative Law on this date; the department has 365 days from this date to complete the regultions.
  
• March 5, 2007: DMHC holds its first public hearing on its first set of proposed regulations. The 14-page regulations (among many other things) spells out exactly how quickly patients should be able to get in to see a doctor in certain situations. (I.E. Urgent primary care needs: 24 hours; Routine primary care needs: 10 days; Urgent spcialty care: 72 hours; Routine specialty care: 14 days).
  
• July 15, 2007: DMHC releases second version of regulations. As in the March version, this draft also contains time-elapsed standards.
  
• September 18, 2007: DMHC holds second public hearing on a revision of the proposed regulations and accepts comments.
  
• December 10, 2007: DMHC's third version of these rules completely strips out all specificity. Gone are state standards requiring that a patient who needs urgent care be able to see a primary care physician within 24 hours. Instead, the new rules allows health plans to define, for themselves, what constitutes "timely access.'' This stripped-down draft shrinks from 28 pages to 7 pages. The Department gives interested parties 15 days to submit comments -- from Dec. 10 - 26. (Note: It's this final 15 days where DMHC gets into trouble).
  
• January 11, 2008: DMHC submits final regulations for approval with Office of Administrative Law. (The Office of Administrative Law has 30 days to approve the regulations -- which it refused to do yesterday.)

Health Access, the sponsors of of AB2179, and consumer advocates have many substantive reasons to scream and howl about the latest draft of the regulations. We believe the state flouted the law, intended to get consumers proper health care when they need it (not weeks and months later). In doing so, we believe they lacked the "statutory authority'' to do what they did. We also believe that the Department was deliberately vague and unclear, allowing insurers to willy nilly make up their own rules.

But what hung the DMHC was its "belief" that the differences between the second and third versions were not substantial (though, anyone who is not color blind looking at all the red in the "track changes'' function could see otherwise.) The Department gave the public only 15 days to comment on the rules -- clearly not enough time for "major changes,'' which require 45 days. But the full 45 days would have meant that the Department blow its January 11 deadline.

What OAL inadvertently did this week was provide consumer advocates time to make the regulations right. That means we'll have another year to fight at the Department level (again) to ensure patients get care when they need it. In the meantime, Health Access will continue to keep advocates abreast of movements on Timely Access and post relevant documents. (We'll post letters, correspondence from the past year soon).

Labels: DMHC, TimelyAccess

posted by Hanh Kim Quach | Permalink | 6:12 PM


 

A Timely Decision...

Perhaps coincidentally with the confirmation hearing of Dale Bonner, perhaps not, the controversial regulations on timely access to care have been dis-approved by the Office of Administrative Law.

We understand the disapproval is on the specific matter that the Department didn't provide enough time for hearings and comment on a substantive change in the regulations.

We actually thought the regulations didn't actually comply with the law in the first place.

Regardless, this gives consumer advocates an opportunity to re-make the case that the regulations need to have clear standards for timely access for care, as the law requires and the Legislature intended.

What isn't acceptable is to let the insurers each set their own standards, so that those standards are hard to enforce, and hard for consumers to even know what their rights are.

Labels: DMHC, TimelyAccess

posted by Anthony Wright | Permalink | 11:36 AM


 

Confirming a Pattern...

The big health care news of today isn't regarding budget or legislation, but a confirmation hearing. Dale Bonner is up this afternoon in Senate Rules Committee to be approved in his post as Secretary of Business, Transportation and Housing. In that Cabinet post, Bonner oversees the Department of Managed Health Care.

This Capitol Weekly article today explains some of the concerns that legislators have raised about the Department's oversight of insurers like Blue Cross.

As the hearing today, Health Access and other consumer groups will be raising significant issues as well, about the DMHC's pattern of deferring to the regulated industry, while ignoring consumer concerns. (UPDATE: Here's Health Access' letter to the Senate Rules Committee.)

The most obvious case is the proposed regulation of timely access to care, where the Department reversed years of drafts of setting clear standards for timely access standards, and instead submitted regulations to let the HMOs set their own standards.

There's other cases, with regard to the implementation of language access rules, and the proposed regulations on discount health plans, where the DMHC has abdicated their oversight role to the industry in question. It's a pattern that needs to change.

Labels: DMHC, TimelyAccess

posted by Anthony Wright | Permalink | 11:08 AM


 

It's time to take action...

Friday, February 08, 2008

HEALTH ACCESS ALERT
Thursday, February 7th, 2008


STATE FAILS TO SET STRONG STANDARDS ON TIMELY ACCESS TO CARE
* Recent LA Times Article Spotlights Issue; Ability to Get Timely Care at Risk
* In Implementation of AB 2179, DMHC Would Let Plans Set the Rules
* New Regs Have No Specific Standards for Consumers to Keep HMOs Accountable

* ACTION ALERT: Call or fax state officials to urge them to withdraw proposed regs, and to set strong and specific standards for timely access to care.

Click here for the Health Access WeBlog: The Next Legislative Leadership; What's Next?; From the Ashes; ITUP Conference; New Paper on Hospital Charging; More on Timely Access


Six years after California passed a law that would guarantee patients an appointment with doctors and specialists in a reasonable timeframe, the state has pulled back on regulations that would have set explicit standards, and are on the verge instead of letting each health plan make their own rules on this important issue.

Consumer advocates, including Health Access California, were dismayed by recent regulations on timely access to care that were proposed by the Department of Managed Health Care (DMHC), the state regulatory agency that oversees health plans in California.

Airlines are not allowed to regularly overbook flights so that passengers are routinely bumped to planes in future months; But HMOs will overbook their provider networks, and without strong oversight, patients are often asked to wait weeks for urgent care, or months to see a specialist.

Care delayed is often care denied. Some patients end up with worse health conditions, while others decide they can't wait any longer and go to the emergency room for more expensive, less efficient care.

ACTION ALERT: Call or fax state officials to urge them to withdraw the proposed regulations on "timely access," and to put forward new rules with strong and specific standards. These regulations will affect every Californian’s ability to obtain a medical appointment, or receive a timely referral to a specialist. Contact:

* Governor Arnold Schwarzenegger, at (916) 445-2841 or fax (916) 445-4633, and
* Secretary Dale Bonner, Secretary of Business, Transportation and Housing the responsible cabinet secretary over DMHC at (916) 323-5400 or fax (916) 323-5440, and
* Director Cindy Ehnes, Director of the Department of Managed Health Care, at (888) HMO-2219 or fax (916) 255-5241.

BACKGROUND: These long-delayed regulations are supposed to implement a law passed in the California legislature in 2002 that guarantees consumers the right to see a doctor within specific times for emergencies, for routine care, or for referrals to specialists. The Office of Administrative Law is now reviewing the current proposed regulations to implement 2002's AB2179 by Assemblywoman Rebecca Cohn, sponsored by Health Access California.

The Department has also limited the scope of these regulations by refusing to apply these rules beyond full-service health plans to specialty plans, such as dental and vision plans.

Rather than following the law that requires the Department to set specific time limits that plans must adhere to, the DMHC is proposing to allow each plan to set and enforce their own, presumably more lenient, requirements that the Department would review.

The Department has also given plans the option to set up more lax alternative timely access standards in geographic areas where plans say it is hard to recruit doctors, especially specialists, such as rural, low-income, or inner-city areas. This regulation would also permit plans to make health care professionals available to give telephone advice to consumers, but only during weekday work hours. If a consumer had what they thought was an emergency after working hours, their only option would be to leave a voicemail message with the health plan for a call back during the next working day or the following week.

Even though the goal of timely access to care has been in the Knox/Keene law regulating health plans since the 1970s, the lack of timely access to health care remains a common complaint by Californians, representing roughly 10% of the complaints that are received by some consumer health advocacy organizations who advise consumers on health care issues. Even though this law was passed six years ago, plan and providers continue to vocally object to the imposition of any measurable time-elapsed standards that the Department could enforce.

These problems were featured in a Los Angeles Times article Tuesday, which spotlights the unfulfilled promise of the legislation from 2002 that has still not been implemented.

Consumer advocates from Health Access California, Western Center on Law and Poverty, and other organizations, have pressed Cindy Ehnes, the Director of the Department of Managed Health Care, to withdraw this version of the regulations on timely access to care. Advocates pledged to participate in an expedited negotiation with the Department and the industry to come up with meaningful and enforceable timely standards that would actually ensure consumers would get timely access to their health care providers.

If you have questions or need more information, please contact the author of this alert, Elizabeth Abbott, Project Director at Health Access at eabbott@health-access.org, or (916) 497-0923, ext. 201.

Labels: DMHC, TimelyAccess

posted by Anthony Wright | Permalink | 2:25 AM


 

It's never time for HMO self-regulation...

Tuesday, February 05, 2008

Really important lead story by Jordan Rau in the California section of the Los Angeles Times today.

We've written before about pending rules at the Department of Managed Health Care on timely access to care, and how important they are for patients trying to get the care they need. They are based on a law, AB 2179 (Cohn) in 2002, that Health Access sponsored.

Well, right before the holidays, the DMHC drafted a new set of regulations that were significantly weaker, and they have already been submitted to the Office of Administrative Law for final review. The regulations are weak enough that we have asked the Governor and the DMHC to withdraw the regulations. Here's the article:

HMO rules stuck in limbo
Three years past the deadline, the health plans are now writing their own standards for timely appointments for patients.

by Jordan Rau

SACRAMENTO -- In 2002, California's HMO czar, Daniel Zingale, declared, "The days are over when they could make patients wait and wait for healthcare."

Zingale was heralding a new law that required his department to ensure that HMO patients received timely appointments with doctors. The law was spawned by the case of a 74-year-old woman who died from an aneurysm in a Kaiser Permanente waiting room while pleading to see her physician.

The Schwarzenegger administration's enactment of the new rules, which the law required by January 2004, has not been prompt. The Department of Managed Health Care did not release its proposed rules until 2007. When HMOs and doctors groups objected to them, the department scrapped the rules in favor of ones that let health plans come up with their own methods of complying with the law. The plans have to submit their guidelines in October, and the department will review them.

Consumer advocates charge that the way the department is putting the law into action controverts the promise six years ago from Zingale, who is now a senior advisor to Gov. Arnold Schwarzenegger and chief of staff for Schwarzenegger's wife, Maria Shriver.

"The pending rules are a betrayal of consumers and of the clear intent of the law," said Anthony Wright, executive director of Health Access California, a consumer advocate group that sponsored and helped write the original legislation. "The department is letting the insurance companies set their own standards."

The industry says they can't meet timely access standards, or the sky will fall. But if that's the case, they have been admitting that they haven't been in compliance with the basic principle of timely access, which has been in the Knox/Keene law since the 1970s.

Imagine if we let the airline industry overbook their flights (or have too few planes) so people are routinely bumped for weeks or months onto other flights. Yet without strong standards, we are letting the HMOs do the same thing with our medical care!

For a good example of why this matters, here's an example from the article:

Bobby Perry, a pharmacy clerk whose employer insures itself and uses Blue Shield of California's provider network, said that for five weeks, Blue Shield could not provide a psychiatrist who would treat her 15-year-old son. He has psychosis that sometimes makes him violent.

Perry, who lives in a Sacramento suburb, said that because she couldn't get an appointment for her son to obtain appropriate medication, she ended up having to call the police to have him institutionalized during an episode.

"Most of the doctors wouldn't take adolescents," she said, while the others "didn't have appointments until one month later.""I asked them what happens in the meantime, and they said, 'Just send him to the emergency room,' " she said....

But "why am I paying insurance," Perry said, "if they're not going to give me services?"

Labels: DMHC, TimelyAccess

posted by Anthony Wright | Permalink | 10:15 AM


 

It's Time for Standards...

Friday, September 21, 2007

HEALTH ACCESS UPDATE
Thursday, September 20, 2007


TIMELY ACCESS TO CARE STANDARDS DEBATED
* Tuesday DMHC Hearing Brings Insurer and Provider Opposition to Consumer Protections
* Consumer Groups Say Delayed Care is Denied Care; Seek Stronger Regulations
* ACTION ALERT: Deadline for Consumer Comments is Friday, September 21st!

New on the Health Access WeBlog: SPECIAL SESSION SPECIAL! What's Next in the Special Session?; Negotiation Next Steps; California and the National Debate; How Many Experience Uninsurance?; Rising Health Care Costs; Governor, Read the Bill!; Lessons from Healthy San Francisco; Assembly Workgroups for the Special Session; More Fallout from the Budget Cuts


The Department of Managed Health Care (DMHC) held another hearing this Tuesday, September 18, 2007 in Sacramento to seek public comment on their second proposed revision to the new regulation governing timely access to care.

This long-delayed regulation is based on AB2179(Cohn) sponsored by Health Access California and passed in 2002. The inability of *insured* patients to get in to see a doctor or specialist is one of the most common complaints that consumer groups get. The lack of ability to get a medical appointment also leads people to unnecessarily go to the emergency room, leading to ER overcrowding and increased medical expenses. The law and regulation are intended to remedy these problems, and protect the value of the coverage for which people are paying.

DMHC wrote these regulations to require that consumers must be able to see a physician within certain prescribed time frames. Some examples specified in the regulation require that consumers see a primary care physician for urgent care within 24 hours, get an appointment for routine care with a primary care physician within 8 business days, or be referred to a specialist for urgent care within 72 hours. DMHC also outlined procedures for measuring performance, tracking compliance, and potential enforcement mechanisms.

INDUSTRY OPPOSITION: Health plans, providers, and their associations spoke against the Department’s regulation as written. They emphatically expressed their clear dislike for any time-elapsed standards. Some in provider community emphasized that this would result in “chaos in the delivery of health care in California ” and would be “very burdensome to administer.” Many medical groups said this regulation would continue to drive doctors to retire or move to other states to practice. Many plan representatives asserted that the implementation of this regulation would be extremely costly and would actually make timely access to care less available. Many providers objected to any tracking or monitoring of whether they actually met even the plan’s own internal standards for timely access and they objected to the imposition of any administrative sanctions or penalties for repeated failure to achieve this minimal performance standard.

There was testimony given that DMHC should drop this regulation entirely, after five years of work, and form a work group of plans, providers, and DMHC staff to formulate alternative standards. Despite the Department’s repeated specific requests, neither plans or providers presented any proposals which included outlines of meaningful alternative standards in place of the Department’s specific time elapsed standards.

CONSUMER RESPONSE: Consumer advocates, including Health Access California, Western Center on Law and Poverty, Health Care Rights Hotline, several mental health advocates, countered these claims at the hearing. They emphasized that this law was passed five years ago and, because of the delay in drafting the regulation, plans and providers had plenty of time to prepare for their implementation.

They argued that the best way to ensure that consumers were afforded timely access to care was to measure how long it took to get a necessary health care appointment. Often the requirement to provide timely access to care uncovers the inadequacy of the provider network, or even so-called “phantom networks” which list more providers as available for appointments than actually are.

Advocates emphasized how the failure to receive timely access to care affects consumers by describing several actual experiences. For example, one patient who had a medical emergency, had to make 19 calls before being able to secure an appointment. Although the plan insisted their network was sufficient, this consumer found many problems. The obstacles she encountered included the listed providers were on vacation, they no longer belonged to the plan, they were no longer taking new patients, they did not have any appointments available for at least 30 days, they had their telephone number disconnected, their voicemail was full, or they did not return phone call messages.

Advocates urged that it was now time to move forward and were generally supportive of the regulation as written. They have asked for some changes, including wanting to close gaps that would have allowed insurers to get out from timely access standards if they declared there was a provider shortage.

The issue was raised again regarding whether it would be acceptable for consumers if they had to forego any entitlement to timely access to care if they required language assistance. This is especially troublesome since the Department finalized their Cultural and Linguistic Access to Care regulation earlier this year, on February 23. This landmark regulation guaranteed low English proficient consumers the right to have health care delivered in a language they understood and written documents provided in multiple languages. Consumer advocates stated unequivocally at the hearing that consumers should not be required to make a “choice” between receiving health care in a language they understood and receiving health care on a timely basis (nor should providers be permitted to make that choice for their patients.) The impact of being forced to make such a decision would be clearly discriminatory.

Action: Consumer advocates are awaiting the Department’s decision whether to make the regulation final as written, to revise the regulation, to invite another round of comments, or to begin the process all over again.

All interested parties should immediately indicate their support of time-elapsed standards by sending comments on Timely Access to Health Care Services (Control No. 2005-0203) by 5:00 pm on Friday, September 21, 2007.

This can be done by email to regulations@dmhc.ca.gov, or by fax to (916) 322-3968 to the attention of the Regulations Coordinator. More information is available on the Department’s website at http://click.icptrack.com/icp/relay.php?r=1019412729&msgid=3702720&act=XQ9M&c=5484&admin=0&destination=http%3A%2F%2Fwww.dmhc.ca.gov%2F&l=3.


For more information, contact Health Access Project Director Elizabeth Abbott, the author of this report, at 916-497-0923, or eabbott@health-access.org.

Labels: DMHC, TimelyAccess

posted by Anthony Wright | Permalink | 12:10 AM


 

We don't even have socialized medicine....

Monday, March 12, 2007

The Wall Street Journal (subscription required) this weekend had a story about the United Network for Organ Sharing is revising its kidney transplant policies -- favoring young patients over old, rather than the length of time on a waiting list.

This change in how kidneys are currently rationed, naturally, has stirred up the age-old debate over whose life should hold more value; who deserves to live and who will die waiting for care?

What's interesting to me, is that without this suggested policy change, there has been virtually no furor over medical rationing in the U.S. Fear of rationing occurs in discussions over "socialized systems'' such as those in Canada or the U.K. that will result in lines and rationing.

But we DO have medical rationing in the U.S. And people die at the rate of 18,000 a year because health care is rationed, according to the Institute of Medicine, making uninsurance the sixth leading cause of death in the United States.

The United States' method of rationing, however, is largely invisible to the middle and upper classes, because they have insurance.

The U.S. medical system current rations care based on who can afford to pay. If you can afford to pay, you see a doctor. If you can't afford to pay, you wait, you get sicker. You might see a doctor -- at an exhorbitant price -- and you are 25 percent more likely to die because of the lack of care you receive.

That's not to say other systems are perfect. In the U.K, for instance, waiting times for elective procedures (such as hip replacements) can be long. On the flip side, waits to see a primary care physician can be shorter than the waits in the U.S., according to an analysis of four countries' health systems.

The United Network for Organ Sharing is heading into a ideological and emotional storm and all new policies must be approved by the U.S. Department of Health and Human Services. These are difficult decisions to make and one could argue that none of us is qualified to judge who is deserving of life or not.

But let's not kid ourselves, just because our policies don't explicitly make those judgements, that rationing is happening today, and it's happening in the U.S.

Labels: ExpandingCoverage, International, InTheNews, TimelyAccess

posted by Hanh Kim Quach | Permalink | 10:58 AM


 

Delayed care often means denied care...

Wednesday, January 24, 2007

Labels: DMHC, Insurers, TimelyAccess

posted by Anthony Wright | Permalink | 3:06 PM


 

Provider rate reductions sort of reversed

 

A Constituency Against Health Care?

 

Progress report

 

Killing us softly...

 

Provider rate cuts put in place today...

 

Deadbeat Insurers

 

"The choice is clear..."

 

Another year, another missed deadline

 

So "never events" never happen...

 

Follow along...